LIKELY TO BE BENEFICIAL

Cognitive Behavior Therapy

One systematic review of three small RCTs and one subsequent RCT found limited evidence that cognitive behavior therapy reduced symptoms at six months compared with no treatment.

UNKNOWN EFFECTIVENESS

Acupuncture

Two systematic reviews and one small RCT found insufficient evidence from heterogeneous RCTs that acupuncture was more effective than placebo in people with episodic or chronic tension-type headache. Many of the RCTs were of poor quality. Some of the RCTs may have lacked power to exclude a clinically important effect.

We found insufficient evidence about the effects of these interventions.

LIKELY TO BE INEFFECTIVE OR HARMFUL

Benzodiazepines

Two RCTs found insufficient evidence about the effects of benzodiazepines compared with placebo or other treatments. Benzodiazepines are commonly associated with adverse effects if taken regularly.

Regular Acute Pain Relief Medication

We found no RCTs. We found insufficient evidence from one nonsystematic review of observational studies about benefits of common analgesics in people with chronic tension-type headache. It found that sustained frequent use of some analgesics was associated with chronic headache and reduced effectiveness of prophylactic treatment.

Definition

The 1988 International Headache Society criteria for chronic tension-type headache are headaches on 15 or more days a month (180 days per year) for at least six months; pain that is bilateral, pressing, or tightening in quality, of mild or moderate intensity, that does not prohibit activities and that is not aggravated by routine physical activity; presence of no more than one additional clinical feature (nausea, photophobia, or phonophobia) and no vomiting.1 Chronic tension-type headache is distinguished from chronic daily headache, which is simply a descriptive term for any headache type occurring for 15 days or more a month that may be caused by chronic tension-type headache as well as migraine or analgesic-associated headache.2 In contrast to chronic tension-type headache, episodic tension-type headache can last from 30 minutes to seven days and occurs for fewer than 180 days a year. Terms based on assumed mechanisms (muscle contraction headache, tension headache) are not operationally defined, and old studies that used these terms may have included people with many different types of headache. The greatest obstacle to the study of tension-type headache is the lack of any single proven specific or reliable, clinical, or biologic defining characteristic of the disorder.

Incidence/Prevalence

The prevalence of chronic daily headache from a survey of the general population in the United States was 4.1 percent. One half of the people with chronic daily headache met the International Headache Society criteria for chronic tension-type headache.3 In a survey of 2,500 undergraduate students in the United States, the prevalence of chronic tension-type headache was 2 percent.4 The prevalence of chronic tension-type headache was 2.5 percent in a Danish population-based survey of 975 individuals.5

Etiology/Risk Factors

Tension-type headache is more prevalent in women (65 percent of cases in one survey).6 Symptoms begin before 10 years of age in 15 percent of people with chronic tension-type headache. Prevalence declines with age.7 There is a family history of some form of headache in 40 percent of people with chronic tension-type headache.8

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4. Rokicki LA,
Semenchuk EM,
Bruehl S,
et al.
An examination of the validity of the HIS classification system for migraine and tension-type headache in the college student population. Headache.
1999;39:720–7.

This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, United Kingdom. Clinical Evidence Concise is published in print twice a year and is updated monthly online. Each topic is revised every eight months, and users should view the most up-to-date version at
www.clinicalevidence.com. If you are interested in contributing to Clinical Evidence, please contact Claire Folkes (cfolkes@bmjgroup.com). This series is part of the AFP's CME. See “Clinical Quiz” on page 797.